Intra-operative anaesthetic management of older patients undergoing liver surgery

Controlled low central venous pressure maintenance level during laparoscopic hepatectomy negatively associated with PHLF incidence: a retrospective propensity score matching study

BACKGROUND

Posthepatectomy liver failure (PHLF), the most serious complication after hepatectomy, may evoke multisystemic complications and even mortality. Despite numerous studies demonstrated the safety and efficacy of controlled low central venous pressure (CLCVP), the optimal central venous pressure (CVP) maintenance level during CLCVP and its relationship with PHLF remain controversial. Therefore, the present study aimed to evaluate the association between the lowest CVP maintenance level during CLCVP and PHLF.

METHODS

755 patients who underwent laparoscopic hepatectomy at Sun Yat-Sen Memorial Hospital between January 2017 and March 2021 were recruited. Univariate and multivariate analyses were performed to determine the effect of the lowest CVP maintenance level on PHLF. After implementing propensity score matching (PSM) to equalize demographic confounders, univariate comparisons and subgroup analyses were conducted to investigate the impact of the lowest CVP maintenance level on PHLF in patients who underwent CLCVP.

RESULTS

Univariate and multivariate analyses identified intraoperative lowest CVP maintenance level < 2 mmHg as an independent risk factor for PHLF (P = 0.041; OR, 0.520; 95% CI 0.277 to 0.974). Following 1:1 PSM in individuals who received CLCVP, the lowest CVP maintenance level < 2 mmHg was associated with heightened PHLF incidence (P = 0.048) and elevated intraoperative lactate level (P = 0.011). Subgroup analyses revealed that the above effect of the lowest CVP maintenance level occurred mainly in elderly individuals or those with prolonged portal blockade.

CONCLUSION

During laparoscopic hepatectomy, excessively low CVP maintenance level should be avoided to decrease the risk of tissue malperfusion and PHLF, especially in elderly or prolonged portal blockade patients.

Case report: dual primary malignancies treated by laparoscopic multiorgan resection with natural orifice specimen extraction surgery

With microtrauma becoming a consensus, in order to improve surgical treatment capability, the clinical application of laparoscopic multiorgan resection is becoming more and more complicated and diversified. Recently, we successfully presented a case of transvaginal specimen extraction surgery that included laparoscopic anatomical left hemihepatectomy combined with laparoscopic total hysterectomy and bilateral adnexectomy and the pelvic and para-aortic lymphadenectomy. The patient, a 75-year-old woman, was hospitalized with abnormal vaginal discharge and bleeding. The pathologic diagnosis of uterine curettage was endometrioid adenocarcinoma. After completing examinations such as color Doppler ultrasound, CEUS, MRCP and thoracoabdominal enhanced spiral CT, preoperative diagnosis was considered as endometrial cancer and a space-occupying lesion in the liver (primary or secondary site)?. No lymphatic or distant metastasis had been found. We also excluded Lynch syndrome by digestive endoscopy and gene sequencing. After a multidisciplinary consultation, the patient underwent surgery under general anesthesia on 24 September 2021. The operation was completed uneventfully in 6 hours, then the patient was transferred to the ICU for follow-up monitoring. The patient began to eat and was able to leave bed on the 4th postoperative day. According to immunohistochemistry, the patient's postoperative diagnosis was intrahepatic cholangiocarcinoma (ICC) and endometrial cancer. Compared with open surgery, laparoscopic multiorgan resection with natural orifice specimen extraction surgery (NOSES) has many advantages such as fewer traumas, shorter recovery time, and better postoperative quality of life. However, combined large-scale laparoscopic surgeries of different organs can be challenging for surgeons and anesthesiologists. No similar cases have been searched.